Provider Demographics
NPI:1174705818
Name:REITZENSTEIN, JONATHAN (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:REITZENSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 LAFAYETTE AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-5092
Mailing Address - Country:US
Mailing Address - Phone:616-336-8800
Mailing Address - Fax:616-336-9700
Practice Address - Street 1:1211 LAFAYETTE AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-5092
Practice Address - Country:US
Practice Address - Phone:616-336-8800
Practice Address - Fax:616-336-9700
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01065869A207Q00000X
390200000X
MI4301102168207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2728217Medicaid